What are the treatment options for a premenopausal woman experiencing heavy menstrual bleeding?

Treatment of Heavy Menstrual Bleeding in Premenopausal Women

Start with the levonorgestrel-releasing intrauterine device (LNG-IUD) as first-line medical therapy, as it reduces menstrual blood loss by 71-95% and has efficacy comparable to endometrial ablation or hysterectomy. 1

Initial Diagnostic Workup

Before initiating treatment, complete the following essential evaluations:

• Obtain a pregnancy test to rule out pregnancy-related bleeding 2, 1
• Measure thyroid-stimulating hormone and prolactin levels to identify endocrine causes of bleeding 2, 1
• Perform transvaginal ultrasound with Doppler as the initial imaging study to identify structural causes including fibroids, polyps, and adenomyosis 2
• Screen for coagulopathies using a bleeding score, as up to 20% of women with heavy menstrual bleeding have an underlying inherited bleeding disorder 3
• Perform endometrial biopsy in women ≥45 years or younger women with risk factors for endometrial cancer (obesity, diabetes, family history, unopposed estrogen exposure) 2, 4

Medical Management Algorithm

First-Line Therapy

Levonorgestrel-releasing intrauterine device (LNG-IUD):

• Reduces blood loss by 71-95%, making it the most effective medical treatment 1
• Efficacy is comparable to endometrial ablation or hysterectomy 1, 5
• Should be strongly considered for women desiring uterus preservation 6
• Counsel patients to expect spotting or light bleeding in the first 3-6 months 1

Alternative First-Line Options

NSAIDs (prescribed for 5-7 days during menstruation only):

• Reduce menstrual blood loss by 20-60% 1, 5
• Most appropriate as initial pharmacologic treatment 1
• Screen for cardiovascular disease before prescribing 1
• Do not use aspirin, as it is ineffective 1

Tranexamic acid:

• Reduces menstrual blood loss by approximately 80 mL per cycle (40-60% reduction) 1, 5
• Effective non-hormonal alternative, particularly useful in patients with fibroids 6
• Absolute contraindication in women with active thromboembolic disease or history of thrombosis 1

Combined oral contraceptives:

• Effectively reduce menstrual bleeding 6
• Particularly appropriate in younger women who also desire contraception 6
• Require careful cardiovascular and thrombotic risk assessment in perimenopausal women 1

Treatment Based on Bleeding Pattern

For Anovulatory Bleeding:

• Start with NSAIDs 1
• Add combined oral contraceptives or progestin therapy if bleeding persists 1
• Consider LNG-IUD for long-term management 1

For Ovulatory Bleeding:

• Start with NSAIDs 1
• Advance to LNG-IUD if inadequate response 1
• Consider tranexamic acid if no thrombotic contraindications 1

Surgical Management

Surgical intervention is indicated when medical treatment fails, is contraindicated, or not tolerated 1:

Minimally Invasive Options:

• Polypectomy or fibroidectomy for focal lesions 4, 7
• Endometrial ablation (performs as well as LNG-IUD with low operative morbidity) 4, 5
• Uterine artery embolization (94% short-term symptom improvement, 85% long-term improvement, though 7% require subsequent hysterectomy) 6

Definitive Treatment:

• Hysterectomy provides complete resolution of fibroid-related symptoms and eliminates recurrence risk 6, 3
• Choose the least invasive surgical route: vaginal > laparoscopic/robotic > abdominal 6
• Vaginal and laparoscopic approaches have shorter hospital stays, faster recovery, and lower complication rates 6
• Studies demonstrate hysterectomy provides significantly better health-related quality-of-life advantage compared to other therapies 6

Critical Pitfalls to Avoid

• Do not dismiss bleeding in perimenopausal women as physiological without thorough evaluation, as endometrial cancer risk increases significantly in this age group 2
• Do not prescribe tranexamic acid in women with thrombosis history 1
• Do not use cyclic progestogens alone for women who ovulate, as they do not significantly reduce menstrual bleeding 5
• Do not dismiss bleeding in the first 3-6 months of IUD use as abnormal, as this is expected 1
• Do not proceed to hysterectomy without trialing medical management first, unless contraindicated 6

Special Considerations

• Women on anticoagulation (particularly NOACs like rivaroxaban) have increased risk of abnormal uterine bleeding (27% vs 8.3% with warfarin), requiring careful counseling and monitoring 6
• Adenomyosis frequently coexists with fibroids and contributes significantly to menorrhagia and anemia in women in their 40s 6
• MRI is superior to ultrasound for diagnosing adenomyosis and should be obtained if initial ultrasound is inconclusive 2